The Palliative Paradigm - A Safety Net Hospital Experience with Covid-19

Abstract

Rationale: The Covid-19 pandemic is the worst healthcare event seen this century amassing a high toll of human life. Covid-19 infection is most commonly associated with acute hypoxic respiratory failure, often requiring intubation leading to multi-organ failure and death. Palliative medicine, during the pandemic, more than ever became in demand especially in ICU settings with a steep increase in consults for pain and symptom management, prognosis clarification and goals of care. We decided to analyze the effect on our palliative medicine service at a safety net hospital at the initial epicenter of the Covid-19 pandemic. Material and Methods: We conducted a retrospective analysis of the Palliative Medicine service at Brookdale University Hospital Medical Center in the months before and after the pandemic from November 2019 to May 2020. We analyzed the number of consults placed per month and the use of IV methadone, novel to our institution used to address breathlessness and pain. To assess the increase in palliative consults we used a linear regression model over time transcending the start of the Covid-19 pandemic. We also queried the orders of intravenous methadone use utilizing pharmacological records, which was only used under the discretion of palliative care and in end of life or terminal settings as is would address breathlessness. Results: Retrospective analysis revealed that in the months leading up to the pandemic including November 2019 through February 2020 there were an average of 80.25± 8.08 palliative consults placed a month. In the months during the initial peak of the Covid-19 pandemic including March and April 2020 there were an average of 162.0± 69 consults per month which then reduced to 69 consults in the month of May 2020. A linear regression calculation was performed which showed an equation of y = 30.6+21.9714X (R2= 0.7794 p=.067). Intravenous methadone was not used prior to the pandemic which was noted to have been ordered 14 times in April 2020 for breathlessness and pain management. Conclusion: We found an increase in the amount of palliative consults placed during the Covid-19 pandemic though not statistically significant with an eventual downtrend. This is thought to be due to distressing symptoms in an acutely life threatening illness and the need for early consultation due to the knowledge and unique skill set that palliative specialists possess. Physicians in acute care settings need be comfortable to consult palliative services early in management.